| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,045 |
2,042 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
1,845 |
1,842 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,234 |
1,233 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,902 |
1,893 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
456 |
456 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
362 |
360 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,299 |
1,297 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$810.48 |
| D1320 |
|
14 |
14 |
$112.00 |
| D1999 |
|
311 |
288 |
$0.00 |